Interpersonal Psychotherapy: The Model IPT is a brief and interpersonally focused psychological therapy for depression. It seeks to maximise the benefit of working in a time-limited manner by maintaining a here and now perspective on what may be recent, recurrent or even chronic mood difficulties, framing the intervention around one of four predetermined interpersonal themes. The process of change in IPT is presumed to be interactive, such that progress in symptom resolution is facilitated by progress in interpersonal resolution and vice versa. That is, if your dispute with your partner starts to resolve you will feel less depressed, in feeling less depressed you will be able to work more effectively on resolving the dispute with your partner. IPT is integrative, in that it combines thinking most characteristic of a medical model – using explicit diagnosis, validating the difficulty of living with depression and emphasising the responsibilities arising from the role of patient, and more dynamically rooted ideas of reciprocal and repeating patterns of relationships, vulnerability arising from broken attachments, and the disadvantage to healthy living consequent to an inability to establish or maintain a meaningful and functionally diverse interpersonal network. IPT employs a flexible structure, moving through three mutually informed phases of work, which help to orientate the therapist and client to the tasks and objectives of each stage. The first phase constitutes assessment, giving particular attention to both the collaborative diagnosis of depression and developing an understanding of the interpersonal context. The overlap between symptomatic and interpersonal experience guides the decision on treatment focus, with four choices available: interpersonal role dispute, interpersonal role transitions, grief and interpersonal sensitivity. The second stage takes on the negotiated focus as the guide, working to alleviate symptomatic experience through the resolution of the primary area of interpersonal difficulty. The final stage of IPT specifically addresses issues of termination of therapy.
Interpersonal Psychotherapy: Key tasks of IPT assessment ESTABLISHING DIAGNOSIS AND INTERPERSONAL ACTIVATION In IPT a diagnosis of depression is made explicitly and collaboratively. This is important to establish a shared treatment target and to ensure that IPT is used with the disorder for which there is an established evidence base. Clarifying the diagnosis and time line of the most recent episode helps to focus attention on the issues relevant to the current episode of depression, familiarising patients with the here and now approach. This also provides an early opportunity to assess, and potentially mobilise, the interpersonal resources available to the patient, which are often underused or poorly directed e.g. who can help you with that difficulty and how?
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A rationale for the method is provided and information about its demonstrated efficacy. This positive presentation is used to combat the despair that many depressed patients feel about their situation and to promote hope in a positive prognosis. This can also help to shape patient’s views away from the self-blame, which is characteristic of depression, and towards the interpersonal context. RELATE DEPRESSION TO THE INTERPERSONAL CONTEXT A detailed review and evaluation of the patient’s relationship network is conducted early in therapy. This helps both to orientate the patient to the interpersonal perspective of the therapy and to begin to prioritise specific areas of interpersonal difficulty for particular attention. Details are collected on the nature and function of current significant relationships, and their association with the onset and maintenance of depressive symptoms. Patients are encouraged to actively evaluate current relationships and to consider how they might be contributing to the current depressive experience. This also provides an opportunity to evaluate the social resources the patient has available to facilitate work on their recovery, and the extent to which these are currently being utilised. Considerable detail is collected during this stage of the assessment and it can be helpful if record is created in exploring the relationships, such as producing a diagrammatic illustration of the patient’s network. The inventory is a means of understanding the current interpersonal context, and clarifying current interpersonal changes, dissatisfactions and conflicts, which may guide focus selection. It is crucial therefore that the future task of negotiating a focus is held in mind when conducting the inventory and used to make enquiries purposeful rather than generic. IDENTIFICATION OF AN INTERPERSONAL FOCUS The interpersonal focus areas are explored during the assessment phase to establish which reflects the primary area of interpersonal difficulty related to the current depression. The different strands of the assessment are drawn together to explicitly link the depressive symptoms to a central difficulty within the patient’s interpersonal situation in a focused formulation. This will form the basis of the second stage of treatment. Many patients experience difficulties in more than one area simultaneously, and by being helped to prioritise one area to work on they are assisted in evaluating the relative impact of interpersonal difficulties on the depression. They are assisted in prioritising energy to resolve difficulties in a specified area, rather than becoming overwhelmed by the enormity of the task they face. FORMULATING AND CONTRACT SETTING Formulation in its simplest form in IPT reflects the selection of an interpersonal area for specific attention. The formulation is made explicit and is negotiated to be personally meaningful for the patient. The patient uses this formulation to guide their participation in the second phase of IPT and this work will be vulnerable if the focus is not collaboratively established. The interpersonal difficulties are explicitly linked to the onset and maintenance of the depressive symptoms, and resolution of these difficulties is presented as the basis for symptomatic recovery. This includes specifying treatment goals the patient would like to work towards within the identified area of difficulty. Interpersonal Psychotherapy
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INTERPERSONAL ROLE TRANSITION
Many of the changes worked on within a transition focus will reflect familiar stages of personal, professional and cultural development, but in the context of depression patients are more likely to experience such changes as a loss. In some instances the loss is readily apparent, e.g. the end of a valued relationship; loss of a job, while in others it may be more subtle, e.g. loss of status with retirement; loss of purpose when adult children leave home. In some cases the change may be ostensibly positive, e.g. a promotion; birth of a child, but still experienced as a loss, e.g. loss of peer group in a promoted post; loss of freedom with responsibility for a child. The model identifies three interrelated phases of the intervention, during which the patient is assisted in mourning and moving away from the old role, re-evaluating the possibilities and opportunities in the transition and clarifying and mastering the demands of the new role to restore self-esteem. In addition it is very helpful to clarify the context of the change and the manner by which it came about. For example, being left by your partner and leaving your partner, will both involve an old role of being in a relationship and a new role of being single, but are likely to be experienced very differently subjectively. Further, as has been demonstrated in the trauma literature, the involvement of another in the change coming about can be predictive of the ease of transition, e.g. being forced out of a job because of bullying compared with leaving a job when funding runs out. The affect associated with each phase is closely monitored to identify and target obstacles to the successful completion of the transition, e.g. incomplete mourning of the loss or apprehension about the demands of the new role without familiar supports. As the intervention proceeds increasing attention is given to the opportunities which are available in the new role, many of which may have been ignored or only partially considered. The patient is assisted in considering all the ways in which they could create and take advantage of new opportunities or re-engage with social and practical support which was not an inevitable loss with the change in role. INTERPERSONAL ROLE DISPUTES
Although relationship difficulties in the context of depression are routinely anticipated within the IPT model, the disputes focus prioritises one problematic relationship, because of its link to the depressive episode, over others for more detailed attention. An individual relationship might become the focus because of an acute crisis or may emerge as the focus due to another change, e.g. a dissatisfying marriage may become more obviously so when the children leave home. The objective is to understand the mechanisms by which the dispute is perpetuated by clarifying and resolving problematic communication patterns and non-reciprocal expectations. Disputes work focuses on detailed reconstructions of unsatisfactory exchanges, reviewing not only what was said but how it was said, how it was received, what was left unsaid and to what extent the communication achieved the desired outcome. Patients seldom provide this level of detail spontaneously and must learn to do so through repeated practice. Once the issues, nonreciprocal expectations and mechanisms of the dispute are clarified, the options for change, through improved communication and use of interpersonal resources, are explored by practicing more direct and empathic approaches. Although IPT is typically delivered as an individual therapy the other party in a dispute is often invited to a session early in treatment to engage them in the work and foster a shared goal of resolution. There is also scope within Interpersonal Psychotherapy
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the disputes focus to review the ways in which the primary dispute is repeated in other relationships, as might be the case if there are undeveloped skills in a specific area, e.g. unassertive communication or avoiding talking about feelings. This is helpful in clarifying the extent of the difficulty and providing opportunities to practice alternatives which might contribute to resolution of the primary dispute. GRIEF
The grief focus is selected when depression following a bereavement creates an obstacle to mourning and sustaining or developing relationships in the remaining network. The goals of this focus help to illustrate to the patient that their experience is not simply the natural consequence of their loss, but also indicative of a mood disorder. The pattern of depressive symptoms is traced through their experience and guides the dyad in understanding how this interferes with functioning in current relationships. IPT encourages the patient to describe the relationship they had with the deceased, starting with the preoccupying memories and working towards a balanced review of the whole relationship. The patient is supported in discussing warded off memories, perhaps related to intolerable feelings or periods of conflict, which characterise many relationships. As with the other focus areas close attention is maintained on the expression of associated affect. Particular attention is given to the period surrounding the death and the ways in which this might have interfered with mourning, e.g. following a suicide or traumatic death, and also to how social support was used at the time and how it can be engaged now. This offers a further opportunity to consider and promote the support which is currently available, and the interpersonal opportunities which remain open to the patient or could be developed. Attention to the remaining network is sustained throughout this work, encouraging opportunities to re-engage or develop relationships which could meet current and ongoing needs. Care is taken to avoid the therapeutic relationship becoming a replacement for the lost relationship, through actively supporting the patient’s use and exploration of the relationships which remain available to him or her. INTERPERSONAL SENSITIVITY The patients for whom Interpersonal Sensitivity is the primary focus often have a history of interpersonal difficulties or isolation extending far beyond the period of the most recent episode of depression. This distinguishes them from many of the other IPT patients, as they may not have experienced a prolonged period of higher interpersonal function, prior to the onset of depressive symptoms, to which they wish to return. Given the more pervasive nature of the interpersonal difficulties these patients experience, it is important to tailor the expectations of therapy accordingly. Given the often long-standing nature of the difficulties, the goals of this area are modest and aim to establish a greater sense of connection with other people. The balance between deepening the connection with existing relationships and establishing new contacts will vary depending on the initial presentation, but there will be an emphasis on making the most of whatever limited resources are presented, often involving the patient in taking hitherto avoided risks. Interpersonal Psychotherapy
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The range of relationships used in the middle sessions differs in Interpersonal Sensitivities, as here and now relationships are anticipated to be scarce. As a consequence, previous relationships are also reconstructed to understand how they worked, the successes which may have been achieved and also the ways in which those relationships became vulnerable and faltered. One of the distinct aspects of work in this focus area is the direct attention given to the therapeutic relationship, which is rare in the other focus areas. In Interpersonal Sensitivities the therapy relationship may be the best illustration, if not the only current information available, on the difficulties the patient encounters in interpersonal contacts. This provides an opportunity to work collaboratively, to understand the difficulties that emerge, providing constructive feedback to the patient which is unlikely to be available otherwise. This also creates repeated opportunities for the therapist to model alternative ways of dealing with the problems the patient repeatedly faces in relationships, often leading to their termination or poor quality ISSUES OF TERMINATION As the IPT sessions conclude increasing attention is given to the end of the therapy relationship, and relapse prevention. It is important to provide information to help the patient normalise response to ending and distinguish an appropriate emotional response from a depressive one. The course and progress of therapy is reviewed in detail with clear attention given to the competencies developed and the way in which this was facilitated by improved interpersonal engagement inside and out of therapy. Comparative measures of depressive symptoms and social functioning are used to focus this discussion. It can also be done by reviewing the interpersonal objectives discussed at the start of treatment, and the progress which has been achieved.
Therapeutic relationship in IPT The therapeutic relationship is of crucial importance in IPT, but is rarely an explicit focus of discussion. The aim is to foster a positive transference as the basis for a collaborative relationship. This is used as a valuable source of information and a basis for modelling an adaptive interpersonal style. However the transference is not an explicit focus and interpretation is rarely used. Rather in IPT, the therapeutic relationship is used to support and encourage focus on the relationships beyond the therapy room. The Sensitivity focus is the main exception to this position because of the assumed paucity of external relationships – defined either by number or quality. In these cases the interpersonal patterns enacted in the therapy relationship are observed and reviewed to aid understanding of the process but even here they are not used an exclusive focus but rather as a pragmatic tool through which external relationships or opportunities might be better understood and utilised. References Weissman MM Karkowitz JC Klerman GL (2000) Comprehensive Guide to Interpersonal Psychotherapy. New York: Basic Books Dr Roslyn Law National Lead for IPT in IAPT
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